Introduction to ECG

ECG stands for electrocardiogram

The contraction of muscle is associated with depolarisation which can be detected

by electrodes attached to the surface of the body.

The work rhythm is used to refer to the part of the heart that controls the spread of
depolarisation. The normal heart rhythm begins in the SA node, so it called sinus
rhythm.

The different parts of the electrocardiogram

P wave is produced by atrial

depolarisation.
The P wave is typically 120-200ms

QRS complex is produced by ventricular

depolarisation. The duration of the QRS
complex shows how long depolarisation
takes to spread through the ventricles.
The QRS complex is typically 80-110ms

T wave is produced by ventricular

repolarisation.

ST segment

The interval between the S wave and the

beginning of the T wave is called the ST segment. If the ST segment is depressed it
indicates ischaemia. If the ST segment is elevated it indicates myocardial infarction.
Some elevation is normal (+/- 1mm).

PR interval

The PR interval is from the beginning of the P wave to the beginning of the QRS
complex. The PR interval represents the time taken for depolarisation to
spread across both atria, through AV node, bundle of his and purkinje fibre to
the ventricles. So, it measures the delay in transmission of action potential
from atria to ventricles. The PR interval should not exceed 0.2 s and loger intervals
indicate a defect in conduction pathway called AV block.

The PR interval should not exceed 0.2s. longer intervals indicate a defect in the
conduction pathway called heart block.

QT interval
The QT interval is measured from the beginning of the QRS complex to the end of
the T wave. It represents the time taken for ventricular depolarisation and
repolarisation. The QT interval is typically 350-420ms

Long Q-T syndrome: if T wave becomes too long (ventricular repolarisation is too
long) early action potentials be generated and if they reach threshold ventricular
fibrillation can occur.

In some ECGs, a U wave can be seen, and it may represent repolarisation of the
papillary muscles. If a U wave follows a normal shaped T wave, it can be assumed to
be normal. If it follows a flattened T wave then it is pathological.

The muscle mass of the atria is small compared to the ventricles, so the
depolarisation associated with the contraction of the atria is small therefore the P
wave is small. The mass of the ventricles is large so the QRS complex is large.

If the first deflection is downward, it is called a Q wave. An upward defection is called

an R wave even if it is not preceded by a Q wave. Any deflection below the baseline
is called an S wave even if it is not proceeded by a Q wave.

The cardiac electrical field/dipole

There are three lead systems that make

up the standard ECG

 Standard limb leads (bipolar):

I,III, III
 Augmented limb leads (unipolar):
aVR, aVL and aVF
 Precordial leads: V1-V6

Standard limb leads

The standard limb leads are used to

display a graph of the potential
difference recorded between two limbs
at a time. In these leads, one limb
carries a positive electrode and the
other limb: a negative electrode. The three standard limb electrodes, I, II and III form
a triangle (Einthoven’s Triangle) at the right arm, left arm and left leg.

The augmented limb leads

Derived from I, II, III to form aVR, aVL, aVF

L-Left wrist

R-Right wrist

F-Left ankle

N-Usually right ankle

Electrical anatomy: sinus rhythm

Initiated by the sinoatrial node

Transverse atria

Through the AV node

Through the bundle of His, Purkinje fibres and left/right bundle branches

The ECG: electrical pictures

A lead is an electrical picture of the heart.

Electrodes detect depolarisation form the surface of the

body. Electrodes are joined to the ECG recorder by wires.
One electrode is attached to each limb and six to the
chest.

The ECG recorder compares the electrical activity

detected in different electrodes and the electrical picture
obtained is called a lead.

When electrical activity is compared between two

electrodes, the view of the heart is called a bipolar lead. A
unipolar lead records the electrical acidity between one
limb and a neutral electrode.

When the recorder is set to lead I is compares the

electrical activity detected by the electrodes attached to
the right and left arms.

12 lead ECG
The ECG is made up of 12 views of the heart. These views are obtained from 6 limb
leads (I, II, III, aVR, aVL, aVF) and six from chest leads (V1-V6).

Limb leads

The 6 limb leads are obtained from three electrodes being attached to right arm, left
arm and left leg.
Lead I, II and III and bipolar. Whereas lead aVR, aVL and aVF are unipolar leads.

aV-augmented voltage
L- left wrist
R- right wrist
F- left ankle
N- usually right ankle
The limb leads look at the heart in the vertical plane. The limb leads consist of 3
bipolar leads (I,II and III).

Chest leads
The chest leads look at the heart in a horizontal plane. The chest leads are unipolar

V1: 4th intercostal space to the right of the sternum

V2 :4th intercostal space to the left of sternum
V4: 5th intercostal space in the midclavicular line
V3: Midway between V2 and V4
V5: 5th intercostal space in the anterior axillary line
V6: 5th intercostal space in the midaxillary
line

The ECG machine is arranged so that

when a depolarisation spreads towards a
lea the stylus moves upwards and when it
spreads away from a lead the stylus
moves downwards.

What does the ECG tell us?

 Heart rate
 Unit of measure is beats per minute
 How large or small heart muscle is.
If there is more muscle mass, there
is more depolarisation through it.
 10mm-1mv
 1 small square-0.1mv
 1 small square=0.04s
 1 large square=0.2s
 To calculate HR
 300/No. of large squares
  1500/No. of small squares
What does the ECG tell us?

More tissue=high voltage

1 small square=0.1mV
1 small square=0.04s

Count the number of squares between beats

300/No. of large squares

1500/No. of small squares

Heart rate lingo

Tachycardia is fast heart rate (greater than 100bpm)

Bradycardia is slow heart rate (less than 50bpm)

What other pathological conditions produce changes to ECG?

If SA node fails to initiate action potential, there is no P wave

If there are no district P waves, then it indicates fibrillation
Atrial saw tooth pattern is when action potentials move in a circular motion in
the right atrium which causes the atria to contract at a faster rate than the
ventricles